CurrentColorado Rocky Mountain Health PlansPolicy N/A

Human Growth Hormone (Florida) Prior Authorization Form - Community Plan

A prior authorization form and instructions for requesting coverage of human growth hormone products for Florida Medicaid recipients on Colorado Rocky Mountain Health Plans' Community Plan. Includes required patient/prescriber information, diagnoses checkboxes, growth testing and laboratory data fields, documentation submission requirements, and contact/fax numbers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHuman Growth Hormone (Florida) Prior Authorization Form - Community Plan

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionForm must be completed in full and faxed to 1-866-940-7328; submit required medical records and lab reports dated within the past 6 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes

Preferred & non-preferredDrug Listing

1-866-940-7328Fax destination

5 yrsDocumentation retention

Policy summary

Authorization requirements (form completion & documentation)

Authorization Requirements

Form must be completed in full. Submit required medical records and lab reports dated within the past 6 months.

Form completion: Form completed in full (incomplete forms may be returned)
See note: incomplete forms may be returned
Patient identifiers: Provide recipient's Medicaid ID, full name, date of birth
Prescriber information: Provide prescriber's full name, NPI, phone and fax
Drug and dosing info: Specify drug, quantity, dosage frequency, height, weight, BMI, date last seen by prescribing endocrinologist
Diagnosis checkboxes: Indicate applicable diagnosis by checking one or more boxes: Documented GH deficiency (treated by board certified endocrinologist); Lowered GH due to aging/obesity/depression; GH deficiency due to pituitary/hypothalamic disease, trauma, surgery, radiation, acquired as adult or diagnosed in childhood; AIDS wasting/cachexia (submit Human Growth for HIV Wasting in Adults (Serostim) Form); Other (specify); Treatment of short bowel syndrome receiving specialized nutrition support (Zorbtive) with date therapy initiated
Authorization for Zorbtive will consist of one four-week course of therapy
Progress notes: Submit progress notes supporting diagnosis
Required: copies of medical records (diagnostic evaluations and recent chart notes)
Pediatric continuation growth data: For children requesting continuation: provide growth information including growth velocity, bone age, height %, growth plate open/closed, mid-parental height
Mid-Parental Height calculated as (father's height + mother's height) ÷ 2, plus 2.5 inches for male or minus 2.5 inches for female
Lab report recency: Provide related test results and official lab reports dated within past 6 monthswithin the past 6 months
All related official lab reports must be submitted
TSH correction: Providers must correct for Thyroid Stimulating Hormone (TSH) deficiency prior to conducting a stimulation test; provide TSH value, normal range, and dateTSH corrected prior to stimulation testing
Provide TSH value, normal range and date
Stimulation testing: submit copies of official test results. Preferred stimulation test is Insulin Tolerance Test (ITT). Levodopa and Clonidine are not adequate agents for adult testing. Provide Test type, Peak GH value (ng/mL), Standard Peak (ng/mL), and date for up to two testsPreferred test: ITT; levodopa and clonidine not adequate for adult testing
Submit copies of official test results for up to two tests
IGF-1 values: Provide previous and recent IGF-1 values with normal ranges and dates if applicable
Include normal range for age and dates
Prescriber signature: Prescriber's signature and date
Documentation retention: Provider must retain documentation for five years5 years
All copies of medical records and labs must be retained for five years

What providers must do

Prior Authorization

Complete and submit prior authorization form

Form must be completed in full and faxed to 1-866-940-7328; incomplete forms may be returned.

Pharmacy PA Call Center: 1-800-310-6826

Documentation Required

Submit supporting medical records and labs

Submit copies of medical records (diagnostic evaluations and recent chart notes) and official lab reports dated within the past 6 months. Copies of stimulation test results and IGF-1 values should be included as applicable. Providers must retain documentation for five years.

Providers must retain copies of all documentation for five years

Documentation Required

Stimulation testing requirements

Preferred stimulation test for adults is the Insulin Tolerance Test (ITT); levodopa and clonidine are not adequate agents for adult testing. Correct TSH deficiency prior to stimulation testing.

Provide TSH value (mU/L), normal range, and date
Stimulation test specifics: Test type, Peak GH value (ng/mL), Standard Peak (ng/mL), and date (up to two tests)

Definitions

Mid-Parental Height(father's height + mother's height) ÷ 2, plus 2.5 inches (male) or minus 2.5 inches (female)

Purpose: This form must be completed in full to request prior authorization for human growth hormone products for Florida Medicaid Community Plan recipients. It is used to document applicable diagnoses (including documented GH deficiency, GH deficiency from pituitary/hypothalamic disease or other causes, AIDS wasting/cachexia, short bowel syndrome (Zorbtive), and other conditions), and to collect supporting clinical information and progress notes.

The form requires submission of related medical records and official lab reports dated within the past 6 months, copies of stimulation test results (preferred adult test: Insulin Tolerance Test (ITT); levodopa and clonidine are not adequate agents for adult testing), IGF-1 values as applicable, and prescriber's signature. Fax completed forms to 1-866-940-7328. Pharmacy PA Call Center: 1-800-310-6826.

Preferred	Genotropin, Ngenla, Norditropin
Non-Preferred	Humatrope, Nutropin, Omnitrope, Saizen, Skytrofa, Sogroya, Zomacton
Zorbtive	Treatment of short bowel syndrome (noted on form)
Serostim	Human Growth for HIV Wasting in Adults (separate form referenced)

OpenPayer

Human Growth Hormone (Florida) Prior Authorization Form - Community Plan

Policy summary

Authorization requirements (form completion & documentation)

Drugs listed on the form

What providers must do

Definitions

Revision history